A medical record consists of a variety of notes entered at various levels by the healthcare providers and professionals during diagnosis, observations, therapies, administration of drugs, test results, reports, x-rays, etc. It is vital to maintain, store, and manage accurate and complete medical records of patients on the part of the healthcare provider.
A medical record includes the following types of information:
- Personal identification information includes name, address, social security number, etc.
- Patient medical history includes allergies, treatment, previous diagnosis, etc.
- Family Medical history includes genetic disorders, cancer, heart disease, and diabetes.
- Patient medication history includes OTC, herbal, prescription medicine, and alternatives.
- Patient Treatment History includes previous treatments, therapies, etc.
Medical directives include a living will that reveals a patient’s wish if in case they are unable to speak for themselves.